Health Information
Evaluation And Treatment Of Male And Female Infertility
Infertility is currently a problem for 1 out of 5 couples presently trying to have children. If after a year of trying to conceive a couple is not successful, a basic infertility evaluation may be started. However, if the female partner in the couple is over thirty or has a significant past medical history of irregular periods of previous pelvic infections, the infertility evaluation and tests can be started earlier.
Any couple embarking on an infertility work-up does so with some fear and reluctance. Some of the common concerns are: What is ahead? How painful is it? How expensive is it? And, what will the doctor find out? The whole world of doctors offices, x-ray departments, and hospitals is stressful for many people. It often does help to know what is ahead, to be informed and aware of how it will feel, and what the doctor is hoping to find. The infertility work-up itself follows a fairly specific sequence. A complete work-up or evaluation of the woman usually takes three or four cycles to complete. This is because certain tests have to be done at specific times in the menstrual cycle. The cost of a complete work-up can be as high as $3,000 if a laparoscopy is indicated. Insurance coverage varies. Some insurance plans do cover various tests relating to infertility; others do not. The nature of the infertility work-up necessitates that it become a priority in your daily life. Suddenly, there are specific days that you must have intercourse. In certain tests you even have to report to the doctor's office a specific number of hours after intercourse. As a result, spontaneous lovemaking becomes difficult. Vacations and business trips become low priority. Schedules have to be made to fit the demands of the testing cycle. Many women find it hard to take time off from work, especially if they don't want it known that they are undergoing an infertility evaluation. It is a stressful time. Both husband and wife are being tested and scored. There is a feeling of "pass or fail" and a real sense of despair if a test comes back showing questionable or negative results. Women often feel frightened and violated by the infertility tests. Men often feel helpless. For the husband, testing is over if the semen analysis is normal. In contrast, he may see his wife having to go through various tests which can be painful and frightening. This understandably can upset both members of the couple. Added to this worry and uncertainty is the lingering fear of what the doctor will find. What if they indeed find an answer, but a discouraging one? Suffice it to say that deciding to start an infertility work-up is a big decision.
The following is an overview of the tests involved. You may want to use it to understand what may be required medically or as a tool to double-check that you have had all the tests.
1. Initial Appointment
Most infertility specialists like to see the couple together for the first appointment. This provides an opportunity for the couple to establish good communication with the doctor. It also is an opportunity to evaluate what, if anything, has been done and what will be needed in the future. The doctor will be able to explain tests to the couple and will give them a time frame in which he or she hopes to complete the evaluation.
The doctor will take a very careful medical history from the couple. He or she will also want to know about the medical history of the immediate family. Attention will be paid to details concerning previous surgery, infections, chronic illnesses, and hospitalizations. Background information on smoking, alcohol intakes, and medications and exposure to environmental or occupational toxins will be requested. Of course, a detailed reproductive history from both partners will be needed. This will include information about when menstrual cycles started, how long they last, quantity and quality of flow, as well as a description of menstrual cramps. Details about the types of birth control practiced will be obtained. In addition, any history of previous pregnancies should be discussed. (Many physicians interview each partner separately so that, if there are details a partner prefer their spouse not know, this can be assured.) Information about previous venereal disease is crucial in the evaluation. A fairly detailed report concerning their sexual history as a couple will be needed. Questions about lubricants and frequency of intercourse will be asked as well.
2. Physical Examination
A physical examination of both partners should be done on the first or second visit. For the woman, this means a general physical with attention paid to the development of secondary sex characteristics, such as breast development and the amount and location of body hair. A pelvic exam will also be done to determine the general size, shape, position, and condition of pelvic organs. A pap smear is routinely taken (to rule out cervical cancer) as well as a gonorrhea culture. The physician will order routine tests on blood and urine to check for general health problems as well.
In the man the physical exam will include an examination of the genital organs, with the doctor noting size, position, and condition of the penis and testes. A rectal exam is done to determine the size and consistency of the prostate gland and seminal vesicles. The doctor will also note the development of secondary sex characteristics. Again, routine blood and urine tests will be done.
3. Ovulation Detection
The doctor may also give the couple instructions about using the basal body thermometer (BBT) to monitor the shifts in body temperature. (See RESOLVE fact sheet: the discussion of pinpointing ovulation - BBT charts and their role in infertility.) Doctors often request 2 to 3 months of BBT charts. This will give the doctor a sense of the general times the woman is ovulating. He or she will use these charts to determine when some of the tests have to be scheduled as many have to be done only at special times in the cycle.
4. Medical Evaluation of the Male
Semen Analysis -- This is the first and most informative test done on the male. An analysis can be done anytime because a man is not cyclic as women are. Abstinence from intercourse for 24-48 hours before the analysis is suggested. Abstinence for a longer period than two days is not necessary. For the semen analysis, the doctor will ask the man to masturbate a specimen into a clean jar. This can be done at home and kept at body temperature and delivered to the lab for evaluation. Then the laboratory will examine the specimen under a microscope looking for the number of sperm present, how fast the sperm are swimming (motility), and the shape of the sperm (morphology). The doctor will also check the total volume of the specimen and its viscosity (thickness).
A fertile semen specimen should have at least 20 million sperm, with at least 50% of the sperm motile, 50-60% with good morphology. Normal volume is 2-5 cc. A semen analysis should be repeated at least once, because all of these levels fluctuate. It is also a good idea to repeat semen analysis periodically if the infertility investigation of the couple is lengthy, as these levels can change over a long period of time.
If the semen analysis indicates that there may be an infertility problem, other tests on the semen will be done. The semen will be checked for the presence of fructose, a special kind of sugar produced in the epididymis. If it is absent this may mean there is a blockage in the ductal system but that spenn production may be normal. In addition, the semen may be checked for unusual clumping or agglutination that could indicate an immunologic response, or a so-called sperm antibody condition. Some physicians also order a new test called the "zone free hamster egg test" to check that the sperm are (in fact) able to penetrate the outer layer of the hamster egg which is very similar in structure to a human egg.
- Several additional test may be done on the male if the semen analysis is not normal.
- Evaluation for a varicocele is done by palpating the scrotum while the man is bearing down or coughing. The link between the presence of a varicocele and infertility is not clearly understood. The most common theory is that the presence of a varicocele causes poor circulation which ultimately inhibits normal sperm production.
- In the event of a subfertile semen analysis, a small biopsy of both testicles may be done. This procedure is done in a hospital under local or general anesthesia. The testicular tissue is examined in the laboratory. This test can tell the doctor if there is an absolute infertile state with no sperm-producing tissue present, or blockage in the vas deferens indicated by the presence of normal testicular tissue yet little or no sperm in the ejaculate.
- Finally, if a blockage in the vas deferens is suspected during a testicular biopsy, a vasography can be done to pinpoint the area of the blockage. This is an x-ray study in which dye is injected into the vas deferens and a series of x-rays are taken.
Medical Evaluation of the Female
Hormonal Evaluation -- This is done through a series of blood tests. FSH levels (follicle stimulating hormone) are checked. Both these hormones are produced in the pituitary gland. Low levels of FSH may indicate that the pituitary gland is not releasing enough of this vital hormone which is necessary to stimulate the egg to ripen in the ovary. Low levels of LH may indicate that the egg is being stimulated to develop but, because LH levels are low, the egg is never released. Blood tests to check thyroid levels and prolactin levels also may be needed. Elevated prolactin can cause irregular ovulation in some women. Testosterone and androgen levels (male hormones) will also be checked if a woman's cycle is irregular. Overproduction of either of these hormones in the adrenal gland or ovary can cause irregular ovulation.
Evaluation of Ovulation -- Doctors like to use the BBT charts and do an endometrial biopsy and/or a plasm progesterone level to document ovulation. The plasm progesterone level is a blood test taken mid-way between ovulation and menstruation. Progesterone, the hormone produced by the ovary after ovulation, is responsible for triggering the build-up of the endometrial tissue or lining of the uterus which is essential if the fertilized egg is to implant and grow. The endometrial biopsy is a test used to evaluate this uterine tissue building up and thickening after ovulation. It usually is done after day 21 of the cycle. This is an office procedure and involves slightly dilating the cervix and putting a small instrument into the uterus which is used to remove a tiny sample of tissue. (The tissue is then examined under the microscope. If the tissue is lush and building up as it should, the doctor can infer that progesterone is present in sufficient quantity and that the woman has a good quality ovulation.) The endometrial biopsy is uncomfortable because the dilation of the cervix causes moderate to strong cramping. Deep breathing using abdominal muscles can sometimes relieve this sensation. Some doctors will use pain medicine as well. There can be slight vaginal bleeding after this test but it is usually minimal.
Evaluation of the Fallopian Tubes -- The hysterosalpinogram is an x-ray used to determine if the Fallopian tubes are open. A radiopaque dye is inserted up through the dilated cervix into the uterus. X-ray films are taken as the dye flows up and out of the tubes. The procedure usually lasts 20-30 minutes. Follow-up x-rays are often required. This x-ray is done in the first part of the cycle to insure that there is no chance of exposing a possible pregnancy to x-ray. This test is uncomfortable. Because the cervix is dilated, there is cramping and an intense feeling of fullness as the dye flows into the uterine cavity. Some women experience shoulder pain after the hysterosalpinogram as well. Again, some doctors will order medication for pain, a local cervical block and/or a medication to help relaxation. It is a good idea to have someone come with you as you may not feel like driving home. That is not to say you will be in pain, but usually women feel tired and weak after the stress of having such a test. The so-called Rubin Test, also known as the test to "blow out your tubes," is rarely done by infertility doctors today. It has been replaced by the hysterosalpinogram. In the Rubin Test, a thin catheter or tube is inserted through the cervix and carbon dioxide gas is pumped into the uterus. It then flows out the tubes, rises and irritates the diaphragm muscles which then causes referred pain to shoulder area. Problems with this test are that there is a possibility that damage could be done to the tissues by the catheter. In addition, if the build-up of gas pressure being measured and recorded is high, it is assumed there is an obstruction, but is impossible to tell where the obstruction is and which tube is involved.
Also, there is no permanent visual record, like an x-ray, that can be used later to compare the pre-and post surgery, for instance. A variety of tests called "endoscopy" allow the doctor to inspect the internal pelvic organs. There are several types of endoscopy exams. Culdoscopy is a procedure in which a slim telescope is introduced into the abdominal cavity via a small incision made in the vaginal wall. The woman is in the knee chest position throughout the procedure. Local anesthesia is usually used. Laparoscopy is a newer and more popular technique used to evaluate the outside of the uterus, the tubes, and the ovaries. It is the most important test used to check for the presence of endometriosis. In this test, the woman is under general anesthesia and in the hospital. The laparoscope is inserted through a small incision near the bellybutton. The abdomen is inflated with carbon dioxide gas to allow for the best possible access to the pelvic organs. If needed, small adhesions or scar tissue can be removed during this test. Dye can also be injected up through the cervical canal and the doctor can observe spilling out the ends of the tubes if the tubes are open and clear. A new endoscopic procedure called hysteroscopy is now being used when a doctor wants to see the internal cavity of the uterus. This involves introducing a small telescope-like device through the cervix into the uterus. General or local anesthesia is used. Any abnormal structures such as septums, polyps, or scar tissue inside the uterus can be examined using this procedure.
6. Male - Female Interaction Evaluation
The main test used to check the survival of the sperm in the cervical mucus is the Huhner test or post-coital test. It is done to ascertain the quality of the woman's mucus as well as the way in which the woman's mucus and the man's sperm interact. This test is done at the time of ovulation when the mucus is most fertile. The couple is instructed to have intercourse without using a lubricant, a specifed number of hours before they see the doctor. (The number of hours can range from two to eight as doctors vary widely in their practice on this.) However, the time interval should be reported and noted by the doctor so the results will be accurate. In the office the doctor takes a swab of mucus and examines it under the microscope. He or she looks for the presence and activity of sperm as well as the quality and viscosity of the mucus. Poor results are indicated if the mucus is thick, if the sperm are not moving well, or if none are present in the cervical mucus. When poor results are discovered, the test should be repeated. (It is important to note that the post-coital should not serve as a substitute for a full semen analysis, as both yield somewhat different information.) Poor post-coitals may also be a clue to the presence of infections, such as chlamydia and t-mycoplasma. It is now felt that certain microorganisms may cause infertility. Many infertility specialists will check couples for one such organism called t-mycoplasma. It is a cross between a virus and a bacteria and can be cultured in the lab by taking a sample of the cervical mucus from the female or a sample of mucus from the penis. This test, as well as others to check for organisms like chlamydia, is expensive but should not be overlooked especially if a couple fall into the so called "normal infertile" grouping where no specific organic reason has been found for the ongoing infertility.
Once an infertility work-up is underway it is important that the couple get the results of each test as they are done. Couples should ask their doctors for explanations if need be. It is your body and you have a right to know what is being discovered. Sometimes it is wise to make a consultation appointment with your doctor if you feel confused or upset about the tests end results. This is especially important if the work-up has been going on for a long time or if there is a male factor problem as well as a female one, which is being treated by another doctor. It is easy to feel helpless and powerless during an infertility work-up. Good communication with your doctor can help alleviate some of these feelings.